Accepted Manuscript

Title: Challenges in management of epidemickeratoconjunctivitis with emerging recombinant humanadenoviruses

Authors: Gabriel Gonzalez, Nobuyo Yawata, Koki Aoki,Nobuyoshi Kitaichi

PII: S1386-6532(19)30004-6DOI: https://doi.org/10.1016/j.jcv.2019.01.004Reference: JCV 4100

To appear in: Journal of Clinical Virology

Received date: 25 June 2018Revised date: 21 November 2018Accepted date: 8 January 2019

Please cite this article as: Gonzalez G, Yawata N, Aoki K, Kitaichi N,Challenges in management of epidemic keratoconjunctivitis with emergingrecombinant human adenoviruses, Journal of Clinical Virology (2019),https://doi.org/10.1016/j.jcv.2019.01.004

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Challenges in management of epidemic keratoconjunctivitis with emerging

recombinant human adenoviruses

Running-title: EKC and novel adenoviral types

Gabriel Gonzalez,a Nobuyo Yawata,b-e Koki Aoki,f,g and Nobuyoshi Kitaichi f,g*

Affiliations:

a Division of Bioinformatics, Research Center for Zoonosis Control, Hokkaido

University, Sapporo, Japan

b Department of Medicine, Ophthalmology, Fukuoka Dental College, Fukuoka, Japan

c Singapore Eye Research Institute, Singapore

d Department of Ophthalmology, Kyushu University

e Duke-NUS Medical School, Singapore

f Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine,

Hokkaido University, Sapporo, Japan

g Department of Ophthalmology, Health Sciences University of Hokkaido, Sapporo,

Japan

*Corresponding author

Nobuyoshi Kitaichi, MD, PhD

Health Sciences University of Hokkaido General Hospital

Ainosato 2-5, Kita-ku, Sapporo 002-8072, Japan

Tel: +81-11-778-7575

Fax: +81-11-770-5034

E-mail: nobukita@hoku-iryo-u.ac.jp

Abstract word count: 190

Text word count: 3237

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Highlights

Sequelae of adenoviral epidemic keratoconjunctivitis can last months or years

Ocular infections by recombinant adenoviruses can be mistyped

Overlooked infections can lead to nosocomial and community infectious

outbreaks

Comparing adenoviruses enabled insights in pathological attributes related to

EKC

Timely treatment against adenoviral infections can prevent lasting consequences

Abstract

Adenoviral epidemic keratoconjunctivitis (EKC) presents as severe conjunctival

inflammations involving the cornea that can lead to the development of corneal

opacities and blurred vision, which can persist for months. EKC is highly contagious

and responsible for outbreaks worldwide, therefore accurate diagnosis and rapid

containment are imperative. EKC is caused by a number of types within Human

adenovirus species D (HAdV-D): 8, 37 and 64 (formerly known as 19a) and these types

were considered the major causes of EKC for over fifty years. Nonetheless, recent

improved molecular typing methodologies have identified recombinant HAdV-D types

53, 54 and 56, as newly emerging etiologic agents of EKC infections worldwide. EKC

cases due to these recombinant types have potentially been underdiagnosed and

underestimated as a source of new EKC outbreaks. Recombination events among

circulating HAdV-D types represent a source of new infectious disease threats. Also, the

growing number of adenoviral types enabled genomic and phenotypic comparisons to

determine pathological properties related to EKC. This review covers the clinical

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features of EKC, current challenges in clinical practice and recent progress in EKC-

related HAdV research, which focuses on the development of novel diagnostic and

therapeutic approaches.

Keywords: human adenovirus; epidemic keratoconjunctivitis; recombination; therapy.

1. Introduction

Human adenovirus (HAdV) strains are the source of multiple infections in human

populations worldwide, including ocular infections, with a broad range of severity [1].

Adenoviral conjunctivitis is caused mainly by HAdV-B 3; HAdV-C 1, 5, and 6; HAdV-

D 8, 19a (renamed 64), 37, 53, 54, and 56 [2-7]; and HAdV-E 4. Epidemic

keratoconjunctivitis (EKC) is a major cause of ocular morbidity in developed and

developing countries and no efficacious therapeutic options are available [8]. HAdV-8

was the first type isolated from an American patient with EKC in 1954, who had

recently returned from Asia [9, 10]. HAdV-64 was subsequently identified in 1973 [11,

12] and HAdV-37 in 1976 [13, 14]. For over half a century, these three viral types

(HAdV-8, 37 and 64) have been considered the major causes of EKC outbreaks

worldwide [15-18].

Analysis of data collected by the Japanese surveillance system for ocular

infections over the last 30 years, reveals a steady increase in the frequency of EKC

cases involving the novel adenoviral types 53, 54, and 56 (Fig. 1), since their first report

in 2008 [19]. The outbreaks caused by recombinant strains in Asia, America, and

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Europe, has led to an increased awareness of the need for global surveillance and

disease control [20]. Current efforts to establish comprehensive criteria in EKC

diagnosis, development of antiviral treatments and prevention measures against

outbreaks are urgently required. This review covers the clinical features of EKC, the

current challenges in clinical practice, and recent progress of EKC-related HAdV

research, which will help to inform the development of novel diagnostic and therapeutic

approaches.

Fig. 1. Transition of EKC causative agents in Japan between 1981 and 2017. The

samples were isolated and reported by the Japanese infectious disease surveillance

system. As detection methodologies and the numbers of sentinel centers changed over

the time period of interest, percentages were compared. Each bar shows the percentage

of isolated samples per HAdV type over a period of 5 years starting with the year shown

on the horizontal axis. The total number of cases is shown on the top of each bar.

2. Clinical features of adenoviral epidemic keratoconjunctivitis and challenges for

diagnosis

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The common symptoms of EKC include severe hyperemia, diffuse infiltration,

lacrimation, follicular conjunctivitis, pseudomembrane formation with potential

permanent symblepharon formation or punctual occlusion, and regional

lymphadenopathy, such as mild swelling of the preauricular nodes [1, 15, 21]. In some

cases, flu-like symptoms are presented such as myalgia and fever [1]. If the infection

extends to the cornea, filamentous keratitis, corneal erosion, and ulceration can occur,

followed by the formation of multiple subepithelial corneal infiltrates (MSIs), which is

induced by inflammatory response [22, 23]. The spotted opacities under the corneal

epithelium can persist for several weeks to months, even years and result in visual

decline, glare sensation, photophobia, and irregular astigmatism [1, 23, 24]. Magnetic

resonance imaging of a typical EKC case revealed an inflammatory process that extends

surprisingly deep into the orbit [25]. A study of 102 suspected EKC cases suggested that

acute bilateral follicular conjunctivitis, intrafamilial infection, and MSI are strong

indicators of EKC in the early stage of infection [15]. However, it should be noted that

>50% of EKC cases do not present MSI.

The EKC incubation period varies between 2 days and 2 weeks, and patients

become contagious after the onset of symptoms for up to 2 weeks thereafter [26]. The

signs of conjunctivitis show at the first stage, and MSIs are observed within 7 to 10 days

after the onset of infection [27]. Although both eyes are easily infected due to the highly

infective nature of adenoviruses, symptoms are generally more intense in the firstly

infected eye [26].

Infections by other agents, such as Chlamydia trachomatis, herpes simplex

virus, Coxsackievirus group type A24 variant (CVA24v), and Enterovirus 70 (E70),

exhibit similar symptoms to EKC and are sometimes difficult to distinguish and treat

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[21]. Punctate hemorrhage in the palpebral conjunctiva is characteristic of adenoviral

EKC and can be distinguished from the multiple spots of small hemorrhage on the

bulbar conjunctiva in acute hemorrhagic conjunctivitis (AHC) caused by E70 or

CVA24v. Although pseudomembranous conjunctivitis is frequently observed in

pediatric EKC, it also can be caused by chlamydia, possibly because the conjunctival

epithelial cell layer is still immature in infants. HAdV-8, 37, 53, 56, and 64, have been

isolated also in sexually transmitted disease clinics in cases of genital ulcers and

urethritis, suggesting eyes and urinary organs serve favorable conditions for the spread

of the EKC-related HAdVs [28-31].

In this moment we have no perfect diagnostic method of EKC clinically and

etiologically, current methods are based on antigen detection by immunofluorescence or

immunochromatography [32-34], culture isolation [35], and molecular methods such as

polymerase chain reaction (PCR), either home brew [36, 37] or commercial kits such as

adenovirus r-gene [38]. Although immunochromatography kits based on antigen

detection are relatively cheap and can be used at clinics with results in 10 minutes [39],

they are limited by the stage of the infection and the number of viral copies present in

the eye with 88-91% sensitivity [40]. Virus isolation in cell line cultures (A549, Hep-2

and HeLa) is used in epidemiological studies of EKC, however, it is time-consuming (2

to > 21 days in some samples) [41, 42] and thus not useful in clinics. Furthermore,

results may be noninterpretable if contaminated with other pathogens [38]. Molecular

methods, such as conventional PCR and real time PCR, are highly sensitive and provide

accurate results in short times; however, besides requiring equipment inaccessible to

general clinics, the heterogeneity among various types limits the development of

universal primers. In addition, proper typing of samples and recombination detection are

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performed by genome sequencing, which can be time-consuming and costly, limiting its

usage to epidemiological studies [43].

Adenovirus identification on samples based solely on the hexon such as antisera

neutralization and partial sequencing of its coding region leads to mistyping of

recombinant types. Furthermore, data for Fig. 1 shows prior to the characterization of

genotypes 53, 56 and 64 as recombinant types, infections by these genotypes were

attributed to the recombinant parental types 22, 15 and 64, respectively, by anti-sera and

partial sequencing analyses (see section 4.2).

Considering the limitations of available diagnostic kits, novel genotypes could

serve as source of EKC outbreaks and thereby facilitate the spread of infectious agents

by impeding their timely containment. Taken together, besides the timely and accurate

virus determination, careful clinical diagnosis is a prerequisite to prevent EKC

outbreaks.

3. Transmission and epidemiology

In Japan, thousands of EKC cases occur annually, according to surveys of occurrence

which collate reports from approximately 600 ophthalmic fixed points nationwide [16,

44]. Peaks are typically seen in the 34th week, mainly towards the end of the summer

season, but nosocomial infections occur even during winter. Similarly, EKC in

Germany is reported more frequently during the warmer humid months [20, 45]. The

frequency of infections in other countries is less understood as only Japan and Germany

implement surveillance measures for EKC [19, 20].

The stable virion structure of adenoviral capsids facilitates the spread of

nosocomial outbreaks by contact with fomites [46, 47]. Infectious virions can be

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transmitted by medical staff by touching towels contaminated with viral particles in

clinics and nursing homes [15]. Therefore, disposal of contaminated materials from

patients and proper hand washing by healthcare staff are highly recommended

preventive practices. The sharing of eye drop bottles among patients should be avoided,

as these bottles can also be contaminated with the virus [24, 40]. Furthermore,

sterilization of hospital instruments by proper methods is indispensable, such as by

autoclaving and disinfection for 2 minutes with 60% ethanol + 10% isopropanol + 1%

n-butanol, 5 minutes with 80% ethanol, 10% iodine, or other compounds effective

against adenoviruses [46-48].

Failed containment of nosocomial infections results in the closure of health

centers and even factories suspected of being the source, which can have serious

medico-social economic impacts [7, 15, 17]. Adenoviral infections manifest as severe

complications in immune-compromised patients, such as infants, transplant recipients,

and AIDS patients [38]; therefore, latent, asymptomatic, chronic and opportunistic

adenoviral infections are potential clinical risks and source of new outbreaks [21, 46]. It

is noteworthy that adaptive immunity against one adenoviral type conferred by a

previous infection is ineffective against infections by types of other adenoviral species

[49]. On the other hand, the immunity conferred by one type against types of the same

species is more difficult to assess due to effects of intraspecies recombination events

[50].

4. Adenovirus identification from EKC cases: history and emerging new types

4.1 History of circulating EKC-related adenoviruses

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In 1954, HAdV-8 was isolated from an EKC case and identified as the previously

undescribed pathogen behind “shipyard eye” disease, which was reported since 1889 in

multiple outbreaks [10]. After 1969, AHC outbreaks were characterized as arising

enterovirus infections [51, 52], which prompted more rigorous surveillance of ocular

infections. After 1973, EKC was also related to a variant of HAdV-19 reported in

Europe and America as 19a [11]; however, closer inspections of strains mistyped as 19a

demonstrated the existence of a third differentiable serotype involved with EKC

outbreaks that was named thereafter as 37 [12].

Fig. 2. PHF nomenclature diagram. (A) Schematic representation of the adenoviral

major capsid proteins on the virion surface. (B) Flowchart for the assignment of novel

genotypes. (C) Illustrative example of the closest types that are phylogenetically

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associated to type 53 in the penton base (P=37), hexon (H=22), and fiber (F=8).

Bootstrap support values are shown next to each branch.

4.2 New typing methods and nomenclature

Occasionally, identification of adenovirus in infections led to contradictory results in

typing of strains by either serology or partial sequencing of the major epitope

determinants, i.e., penton base, hexon and fiber (Fig. 2A-B) [53, 54]. Subsequently,

phylogenetic analyses of complete genome sequences were employed to resolve the

genetic relatedness of the strains which supported a recombinant origin in many cases

[3-6, 50, 55]. Therefore, new types are denominated as genotypes due to their genomic

characterization, and they are referred to by the distinct recombination in the penton

base, hexon, and fiber (PHF) open reading frames (ORFs) [43]. The genotype for each

ORF is assigned as the closest reference genotype clustering in the respective

phylogenetic tree (for example see Fig. 2C) [43].

Initially, type numbers were assigned based on serological analysis, leading to

serotype numbering from 1 to 51 [9, 56, 57]. However, the advent of more affordable

and rapid molecular typing methods revealed mistyped strains [6, 58]. These strains

have been progressively re-classified and demonstrated to be increasingly circulating

and responsible for outbreaks since 2000 [19, 59] (Fig. 1). Currently, more than 80

genotypes, including 51 serotypes, are classified into seven species, A to G, based on

nucleotide and deduced amino acid sequences [60, 61]. HAdV-D is the most type-

diverse species in the genus with >50 genotypes, including many with recombinant

origins (Fig. 3A and Table) [50, 62, 63].

Table. PHF classification of novel genotypes related to EKC

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Genotype Protein Clustered type Closest type a Nucleotide

identity (%) a

Bayesian posterior

probability b

Percentage of

bootstrap support c

53 penton base 37 37 100 1·00 100

hexon 22 22 98 1·00 100

fiber 8 8 100 1·00 100

54 penton base 54 45 94 - 48

hexon 54 9 91 0·95 48

fiber 8 8 97 1·00 100

56 penton base 9 9 99 1·00 100

hexon 15 15 99 1·00 100

fiber 9 9 99 0·87 61

64 penton base 22 22 98 1·00 100

hexon 19 19 98 1·00 100

fiber 37 37 100 1·00 100

a Closest type identified by BLAST.

b Posterior probability estimated by MrBayes v3.0 with 1 million states.

c Percentage of bootstrap support estimated by RAxML v8.2.10 with 1000 repetitions.

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Fig. 3. Maximum likelihood inferred phylogenetic trees for human adenovirus D. The

phylogenetic trees for human adenovirus D types using the whole genome (A) and the

opening reading frames for penton base (B), hexon (C), and fiber (D) were inferred with

maximum likelihood approaches in RAxML using a general time-reversible

evolutionary model allowing for invariant sites and heterogeneity among sites modeled

with a gamma distribution (GTR+G+I). Bootstrap support for the branches is shown

with 1000 repetitions. Novel types are highlighted in red and types clustering with the

novel types are highlighted in blue. Types reported to be intermediary forms of type 53

are shown in green in (A).

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4.3 Emerging new HAdV types

Adenovirus 53 [P37H22F8]

The first report of EKC caused by HAdV-53 was in 2008 from a retrospective study of

a Japanese outbreak that occurred in 2003 [5]. A comparison of partial nucleotide

sequences derived from the hexon and fiber ORFs suggested a mosaic between types

22, 37, and 8 (Fig. 3 and Table). A similar report of EKC cases in 2005 from Germany

involved strains serotyped as 22 [64], and subsequent phylogenetic analyses (Fig. 4A)

led to the conclusion of a recombinant origin [65]. Notably, HAdV-22 was firstly

isolated from an infant with trachoma [66]. A subsequent study compared the genomes

of strains related to HAdV-53 isolated in 1987, 1989, and 1995 [2]. The recombination

analysis provided evidence that the strains 53-like were intermediate recombinant

genomes between types 22/37 and the currently circulating HAdV-53, which, in the

latter case, evidenced a fiber ORF identical to HAdV-8 [2]. In another study, based on

our clinical observations, infections by HAdV-53 seems to be more frequently related to

milder infections without corneal inflammation than cases involving HAdV-8 and 37

(manuscript in preparation). The number of reported cases per year vary, but HAdV-53

remains a frequent cause of EKC in Asian countries [19].

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Fig. 4. Putative recombinant origins of genomic regions in novel types. Genomic

distribution of recombined regions for novel types 53 (A), 54 (B), 56 (C), and 64 (D).

The boundaries of the putatively recombined regions were determined by the

recombination detection program (RDP). The putative recombinant parent of the

recombined block is shown in parentheses. At the the bottom of the diagram, the

annotation of the human adenovirus D genome is shown as a reference. Positions shown

are relative to the alignment and the encoding regions corresponding to penton base,

hexon, and fiber (PHF) are highlighted in red.

Adenovirus 54 [P54H54F54]

HAdV-54 was first reported in 2000 from a nosocomial outbreak at a university

teaching hospital in Japan. Initially, isolated strains were mistyped as HAdV-8 due to

cross-reactivity in serological analyses [3]. The complete genome sequence analysis of

these strains identified them as a novel genotype: HAdV-54 [3]. Despite a Greek group

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recently reporting a strain with a partial hexon similar to HAdV-54 [67], all

characterized cases to date have been limited to Japanese EKC, whereas the related

HAdV-8 has steadily decreased in reported frequency (Fig. 1) [19, 57, 68]. HAdV-54

clusters monophyletically with HAdV-8, which is associated to severe cases amongst

the EKC-related types [1, 10, 66]. Although serological analysis showed some cross-

reaction with antiserum against serotype 8, and less so with serotype 9 [3], comparisons

of hexon proteins at the amino acid level confirmed high pairwise identities with these

types. HAdV-8 and 54 possess >95% similarity to each other along their entire genome

sequences. However, ORFs for penton base and hexon show lowered similarities, <95%

and <90%, respectively, which has been suggested as evidence of ancestral

recombination events (Fig. 4B). The reason behind the lack of reports pertaining to

HAdV-54 prior to 2000 is unclear.

Adenovirus 56 [P9H15F9]

HAdV-56 was initially reported from cases in France and Japan. The cases in France in

2009 corresponded with a neonatal respiratory fatality with subsequent conjunctivitis in

the health care workers who cared for the child [55]. In contrast, the report in Japan

corresponded with 11 EKC cases disseminated across the country in 2008 [4]. The

recombination and serological analyses of the virus genome demonstrated a

recombinant origin involving types 26, 15 or 29, and 9 (Fig. 4C). The frequency of EKC

cases attributable to HAdV-56 has since been increasing across Japan [19].

Interestingly, adenoviral ocular infections by intermediate strains between types 15 and

9 were reported in Europe in 1968 and the USA between 1970-1980 [69, 70],

suggesting an earlier origin for HAdV-56 that passed undetected or was mistyped by

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serological approaches. Notably, HAdV-56 was identified as the cause of a large EKC

outbreak in China in 2012 [59].

Adenovirus 64 [P22H19F37]

HAdV-19 was first reported in 1955 from a case of trachoma in Saudi Arabia [71]. A

strain with a similar serotype, but a strikingly distinct restriction enzyme pattern, was

isolated 20 years later from EKC cases [72]. Therefore, following the naming

convention of that time, the serotype and a letter representing the distinctive enzyme

restriction pattern were assigned to this strain: 19a. Recombination and phylogenetic

analyses of each protein from HAdV-19a demonstrated that the penton base and hexon

ORFs are recombinant regions with higher similarity to HAdV-22 and 19, respectively,

than to HAdV-37, which is the putative origin of the genome backbone (Fig. 4D) [73].

The name HAdV-64 was assigned to the strain previously named ‘19a’ to recognize

both the recombinant origin and its independence from HAdV-19 [6].

5. Uncovering unique properties of HAdV-D related to ocular infections

The fiber protein is an important determinant of tissue tropism [74], and possibly a

factor limiting EKC to a subset of types that share phylogenetically related fiber

proteins (Fig. 3D). The fiber knob has been suggested to be under positive selection

[75], which favors amino acid compositions that bind cellular receptors in the ocular

tissue. Fiber knobs of EKC-related types are predicted to have unusually high isoelectric

points, enabling electrostatic interactions [76, 77] to receptors, such as sialic acid-

containing oligosaccharides [78-81]. Notably, EV70 and CVA24v, which are associated

with AHC, also bind to cells via sialic acid-containing glycans, supporting a link

between receptors with sialic acid moieties and severe ocular diseases [82]. These

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observations have been used to the design of sialic acid analogs for topical treatment of

EKC by blocking the initial attachment of fiber knobs in the adenoviral virions and

facilitating their agglomeration and removal from the tissue [81, 83, 84].

Besides the genes encoding the major capsid proteins, other genomic

recombination hotspots are important sources of genetic variation between types [50].

These hotspots localize in the E1, E3, and E4 transcriptional regions and encode

proteins implicated in modulation of viral replication and the host immune response

(Fig.4) [85, 86]. These regions have been shown to exhibit phylogenetic correlation, i.e.

coevolution, despite being the target of frequent recombination events [62].

Furthermore, comparisons of phylogenetically related protein sequences in EKC- and

non-EKC types have suggested fiber and proteins encoded in E3 as possible

pathogenesis factors associated with the severity of EKC cases [62, 75, 87, 88].

Systematic studies of the adenoviral E3 region subsequently revealed

multifunctional proteins that target various host factors, effectively modulating diverse

host processes. Notably, CR1β, a 49kDa protein uniquely expressed by HAdV-D, is

secreted from infected cells to target other uninfected immune cells, such as natural

killer (NK) cells, with immune-suppressing effects [88, 89]. Among the human

receptors identified as interacting with CR1β, two striking groups include signal

lymphocytic activation molecule (SLAM; CD150) family receptors and leukocyte

immunoglobulin-like receptor subfamily B member 1 (LILRB1) and 2 (LILRB2)

inhibitory receptors expressed in immune cells [89], and variations in the binding

proteins was observed between different types and cell lines [90]. CR1β binds motifs

present in CD45 isoforms expressed on leucocyte cell membranes [88]. EKC-related

types putatively escape from conjunctiva NK cell immune responses by modulating the

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NK cell subpopulations and altering the expression of ligands for the activation of NK

cell receptors in infected cells [91].

6. Challenges in understanding the pathogenesis of EKC and in development of

therapeutics for EKC

In general, there is no specific antiviral treatment against adenovirus infections [92]. If

inflammation or infiltration of the cornea is detected, eye drops with anti-inflammatory

agents or corticosteroids are recommended; however, the latter should be restricted to

complicated cases, as animal studies and a clinical trial showed the use of topical

corticosteroids extend the duration of the infection despite alleviating the discomfort in

patients [92-94]. Cases presenting MSI can be treated with topical 0.05% cyclosporine

A or 0.03% tacrolimus to shorten the infection and clear the MSI [95, 96]. A recent

double blinded clinical trial reported near complete recovery and absence of MSI on day

5 by treating the EKC infection four times a day with drops containing povidone-iodine

1.0% and dexamethasone 0.1% [92]. In EKC, pseudomembranous conjunctivitis can be

mixed with streptococci infections that lead to corneal perforation; therefore, antibiotics

should be applied prudently. Neonates are at risk of mixed infections with bacteria;

therefore, antibacterial eye drops should be applied [20].

The interactions of virus and host innate immune system are suspected to play a

role in the corneal infiltration developed only in a subset of patients infected with

HAdV-D [91]. Identification of the mechanisms behind corneal infiltration and

development of therapeutics have been hindered by the lack of proper animal models

that recapitulate the immune conditions of the ocular tissue. Some alternatives have

been suggested, each with distinct advantages and drawbacks. For example, the viral

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replication of HAdV-37 in a porcine cell culture system [97] and three-dimensional

culture system with human cells [98] are in vitro systems that allow experimentation but

lack the intricacies of the complete ocular tissue. On the other hand, using the mouse as

an animal model, despite offering such anatomical complexity, has the drawback that

human adenoviruses do not replicate in the mouse cornea [99], as well as the intrinsic

differences between the human and mouse immune systems, particularly at the level of

innate immunity [100].

7. Conclusions

Timely diagnosis of EKC requires careful clinical observation and sensitive virus

detection assays, which are not yet available in most clinics. Since effective therapeutics

against EKC are also unavailable, the best clinical practice remains relying on

implementation of prevention and containment measures following the timely reporting

of newly detected outbreaks. New genotypes are potentially overlooked and may

constitute sources for new EKC outbreaks. Recombination events among circulating

HAdV types are a steady source of potentially emergent threats and subsequent spread

in immunologically naïve populations. Therefore, proper identification of the new types

is particularly important to control EKC outbreaks. More detailed characterization of the

clinical features, genomic analysis of new types and the development of model systems

are imperative to deepen our understanding of EKC and develop efficacious

therapeutics.

Author contributions

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G.G., N.Y., K.A. and N.K. equally contributed to the conceptualization, data curation,

formal analysis and gather and review of references. G.G. wrote the original draft. N.Y.,

K.A. and N.K. reviewed and edited the text according to their clinical experience.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public,

commercial, or not-for-profit sectors.

Funding: None

Competing interests: None declared

Ethical approval: Not required

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